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["REQUIRED INFORMATION FORM (RIF) - Undergraduate Students"]
["Information must be completed and verified prior to submitting to the contact person at the healthcare facility 4-6 weeks prior to clinical start. Missing or incomplete information will result in students/faculty being delayed or denied. NOTE:  copies of all required information contained in RIF are kept by schools in student file and will be made available to the healthcare facility at any time requested during normal business hours.  The RIF is done is lieu of hard copies being sent regarding each box below, so accuracy and filling out completely is important.  Thank you!"]
[]
["Name of School      ",null,null,"Semester / Year:",null,"Type of Student"]
[]
["School Requestor Name",null,null,"School Requestor Email",{"$nulls":4},"School Requestor Phone"]
[]
["School Faculty Name (not Healthcare preceptor)",null,null,"School Faculty/Instructor Email         ",{"$nulls":4},"School Faculty/Instructor Phone        "]
[]
["Healthcare Organization Name and Location of Clinical",null,null,"Healthcare Organization Preceptor name ",null,null,"Clinical                     START DATE","Clinical                                             END DATE","Total # of Onsite Clinical hours (per student)   ","Access to Electronic Medical Record Needed? (Y/N)",null,"C19 Vaccination:","Organizations may still be required to document current/past vaccinations for COVID-19.  if the student has had any COVID-19 vaccinations, list manufacturer/dates here.  If none to date, list NONE."]
[{"$nulls":11},"(enter information in the columns to the right, below) "]
[]
[null,"Student/Instructor Name",null,null,"Month/Date of Birth: (ex: 03/26)","Dept/ Unit of Clinical","Student Email ","Home Phone#  w/ area code","Health Reqs & Influenza Done            (Y/N) ","Back ground Checks      (Y/ N)","AHA CPR/BLS      (Y/N)","Completion DATE of Forms A/B:","Form C (list first clinical date onsite)","Grad            Date (Yr/Month) Ex: 2022-05","C19 Vaccination Info (details above)",null,"C19 booster- Y/N   If yes, brand and date?"]
[]
[null,"Last","First","MI"]
[]
[1,{"$nulls":13},"Ex: Pfizer 1/21/21, 2/22/21",null,"Ex: Pfizer 11/21/21"]
[2,{"$nulls":11},"     "]
[3,{"$nulls":11},"     "]
[4,{"$nulls":11},"     "]
[5,{"$nulls":11},"     "]
[6,{"$nulls":11},"     "]
[7,{"$nulls":11},"     "]
[8,{"$nulls":6},"     ",{"$nulls":4},"     "]
[9,{"$nulls":6},"     ","     ",{"$nulls":3},"     "]
[10,"     ","     ","     ","     ","     ","     ","     ","     ",{"$nulls":3},"     "]
[11,"     ","     ","     ","     ","     ","     ","     ","     ",{"$nulls":3},"     "]
[12,"     ","     ","     ","     ","     ","     ","     ","     ",{"$nulls":3},"     "]
["For instructions to complete this form, please see Step 1 on School Coordinator page: http://www.fvhca.org/SchoolCoordinators.html"]
[]
[]
[]
[]
["     "]
["Signature and Title of School Representative",{"$nulls":11},"Date"]
[]
[]
["Revised 3/20/24"]

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